Posts Tagged ‘Surgeons’

Philippines: Doctor Shortage — Why Not Pay Tuitions With Government Funds To Get More Doctors? (Editorial)

(The Philippine Star) | Updated March 19, 2017 – 12:00am

Taxpayers spend P2.5 million over four years to produce a graduate of the Philippine Military Academy. Why not make the same investment in producing surgeons and other physicians?

The proposal was made by Senate President Pro Tempore Ralph Recto, who noted that the Department of Health already has an existing scholarship program for aspiring doctors. All that’s needed is to expand the program while at the same time making compensation and benefits more attractive for physicians working for the DOH.

Unless remuneration is improved, the nation may see its shortage of doctors worsen, especially in rural areas. Recto noted that of the 946 available slots in the government’s Doctor to the Barrios program from 2015 to 2016, only 320 were filled. The program is meant to provide at least one doctor in each low-income municipality, but there were few takers. Those 626 unfilled slots meant that millions were deprived of the services of a doctor in their communities.

The medical profession can pay handsomely – but only after many years of grueling studies and substantial financial investment in schooling and specialized training. The cost of medical textbooks alone can be beyond the reach of a low-income household.

Parents who have invested their life savings to send their child to medical school would naturally be reluctant to let the new doctor volunteer for a rural assignment that pays P56,000 a month, especially in conflict zones. The medical community is still waiting for justice for a Doctor to the Barrio volunteer, Dreyfuss Perlas, who was shot dead by still unknown assailants last March 1 while serving in Lanao del Norte.

If the government shoulders the schooling expenses of deserving medical scholars, the nation may be assured of a steady supply of physicians, even if the beneficiaries leave the DOH after a mandatory four-year service. The government may then have at least one doctor for every municipality, with the scholars encouraged to serve in their hometowns.

Health experts estimate that the country currently faces a shortage of 60,000 doctors. This means six out of every 10 Filipinos die without seeing a doctor. This need not be the case. The government is recruiting more police and military personnel. Why not boost resources to produce and recruit more doctors?

Britain: National Health Service (NHS) hospitals are to be banned from fitting most metal-on-metal hip replacements after a study found unacceptably high failure rates among implants in 17, 000 patients

NHS hospitals are to be banned from fitting most metal-on-metal hip replacements after a study found unacceptably high failure rates among implants in 17,000 patients.

The devices have already been subject to safety alerts, amid fears they can leak toxic metal. Surgeons are concerned that they fail far too early as joints wear away.

Two common models have been taken off the market and thousands of patients fitted with the implants have been told to have annual checks, often including blood tests.

New draft guides drawn up by regulators say the NHS should stop using any hip implant with a failure rate higher than five per cent at five years. It means that almost every type of metal-on-metal hip implant — including five more devices still used — should no longer be fitted in patients.

The ruling comes after a series of investigations into the devices by The Telegraph, which uncovered widespread problems.

The warning from the National Institute for Health and Care Excellence (Nice) has been issued after research uncovered failure rates as high as 43 per cent among some of the implants.

An audit of all hip surgery in England, Wales and Northern Ireland found that most types of metal-on-metal hip devices in use had failure levels below the standards Nice deems acceptable. The traditional varieties use a metal ball in a plastic socket.

One device, the DePuy ASR, which was withdrawn when manufacturers admitted to failure rates of 13 per cent within five years, required revision surgery in almost a quarter of cases within that period. After nine years, failure rates are estimated to be 43 per cent, the audit says.

When a similar model was used in hip resurfacing procedures — an operation introduced to achieve better results for younger, more active patients — failure rates were 14 per cent after five years, and 36 per cent after nine years. Both types of implants were given to almost 6,000 patients. Six metal-on-metal models and a ceramic-on-metal model implanted in more than 11,000 resurfacing patients had five-year failure rates of five per cent or worse.

Some rose to 16 per cent within nine years, the figures show.

The metal-on-metal resurfacing models found to have such high failure rates are: the Adept; Cormet 2000; Durom; Recap Magnum; and Conserve Plus.

A sixth device, the Corail/Pinnacle full hip replacement using ceramic on metal, also failed to meet the standard.

Just two types of metal-on-metal device in current use fall within the proposed national standard — and only barely — the figures show. Stephen Cannon, an honorary consultant surgeon for the Royal National Orthopaedic Hospital, welcomed the report.

He said: “I think there is a question about whether it goes far enough, but this is definitely a step in the right direction — it amounts to a ban on most of them.

“The figures speak for themselves — even the best metal-on-metals have four times the failure rate of the rest. This is a really significant problem because these were given to an awful lot of people.”

Senior surgeons said the full scale of the failings in hip replacements given to thousands of men and women was only now becoming clear. Martyn Porter, past president of the British Orthopaedic Association, said: “It first started to become apparent among surgeons about three years ago.

“We were starting to see high revision rates but this is like watching a car crash in slow motion — at first, you just don’t know how bad it is going to be.”

He said the scale of the problem was “extremely disappointing”. He said: “These devices, which were supposed to be innovative, had such poor results.”

Mr Porter said any patients who suspected problems with a metal-on-metal device should see their doctor.

“The important thing is identifying and investigating the cases where there are problems because if you leave it too long it can cause tissue destruction.”

Senior surgeons said their results still compared badly with those of traditional hip replacements. Some called for all types of the implant to be forced off the market.

The devices were introduced in the 1990s, but became most popular among surgeons over the past decade, with more than 11,000 a year being implanted by 2008 because it was hoped that they would offer better results.

DePuy said rates of revision on its Corail/Pinnacle ceramic-on-metal device might be lower than five per cent when data confidence intervals were taken into account.

Corin, the makers of Cormet 2000, said it had produced excellent clinical outcomes since being introduced in 1997. The manufacturers of Adept, Durom, Recap Magnum and Conserve Plus did not respond to calls.

Britain’s National Health Service cannot guarantee the safety of millions of hospital patients as nursing assistants are carrying out the work of doctors with no training, a government report warns today.

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Health secretary Jeremy Hunt Photo: Rex Features

By Tim Ross, Political Correspondent

The Telegraph

Elderly people receiving care services are also being left at risk because some untrained staff are sent into frail pensioners’ homes, according to the Department of Health review.

The report, written by the writer and health campaigner Camilla Cavendish, found that some healthcare assistants were carrying out tasks that should be done by fully trained doctors or nurses.

Support staff are undertaking tasks such as placing fluid directly into patients’ veins by inserting intravenous drips or taking blood, but they receive no “consistent” preparation for the work, the report said.

The review, initiated after the publication of the public inquiry that revealed that the most basic elements of care were neglected at Stafford Hospital, called for all healthcare assistants (HCAs) to receive standard training.

Robert Francis QC, chairman of the public inquiry into the failings at Mid Staffordshire NHS Foundation Trust, recommended a registration system for healthcare support workers.

But Health Secretary Jeremy Hunt refused to initiate full-blown regulation for HCAs, saying that it could lead to a “bureaucratic quagmire”. He instead commissioned the latest review, led by Ms Cavendish.

Healthcare assistants and support staff in care homes are responsible for some of the most basic levels of care in the health service including washing, dressing and feeding patients.

The review found “pockets of excellence” which recognise the importance of training their support staff.

“But overall, training is neither sufficiently consistent, nor sufficiently well supervised, to guarantee the safety of all patients and users in health and social care,” it said.

In domiciliary care, we have heard of instances of staff being sent unsupervised into clients’ homes with no training.”

Healthcare assistants (HCAs) have “no compulsory or consistent training”, and a profusion of job titles.

Patients are confused, often assuming that everyone around them is a trained nurse.

Some nurses, however, are “not always sure which tasks they can safely delegate” to their support colleagues.

“Some HCAs are now doing jobs that used to be the preserve of nurses, even doctors,” the report said.

“The review met a group of healthcare assistants from a busy A&E who are inserting IV drips, taking blood and plastering. Yet they are paid at three levels below a newly qualified nurse.”

There is no standard training for staff who provide fundamental care in NHS hospitals and care homes.

The review says there are there are more than 1.3 million frontline staff who are not registered nurses but who deliver the bulk of hands-on care in hospitals, care homes and in the homes of people needing support.

It concludes that all HCAs and social care support workers should undergo the same basic training and earn a “Certificate of Fundamental Care” before they can handle patients without supervision.

When HCAs earn the qualification they should be allowed to use the title “Nursing Assistant”, it said.

Jeremy Hunt, the Health Secretary, welcomed the findings but stopped short of promising to introduce the recommendation for compulsory basic training.

The government will provide a full formal response to the report in the autumn.

What, if anything, should be done to alleviate the predicted doctor shortage in the U.S.? The Wall Street Journal put this question to The Experts, an exclusive group of industry, academic and other thought leaders who engage in in-depth online discussions of topics from the print Report. This question relates to a recent articlethat debated whether residency programs should be expanded to produce more doctors and formed the basis of a discussion in The Experts stream on Wednesday, June 19.

I hope that many readers are now aware of the Institute of Medicine’s 2010 report that identifies nurses as a key component to addressing the health-care needs of the nation, especially the need for primary-care providers. Subsequent reports continue to support this idea, especially as the Affordable Care Act moves through its various stages of implementation.

Nurses, in particular advanced practice registered nurses (APRNs), are efficient at providing primary care—from both cost and patient experience perspectives. They receive extensive education and training that is carefully regulated through national standards for curriculum and certification examinations. APRNs must prove their proficiency through national boards, similar to how most medical specialties are regulated. APRNs practicing at the full extent of their education and training make health-care systems more efficient at providing quality care, allowing all members of the team to focus on their specialties.

That said, one concrete step we can take toward improving access to care is to encourage state legislatures to update rules of practice for APRNs—the largest group of which are nurse practitioners (NPs). As the National Association of Governors concluded in 2012, “Most studies showed that NP-provided care is comparable to physician-provided care on several process and outcome measures.” Moreover, the studies suggest that NPs may provide improved access to care. Currently, 19 states and the District of Columbia allow APRNs to practice to the full scope of their training, and such legislation is being considered in several more states. Meanwhile, the remainder of the country struggles against practice barriers that are inefficient and restrict critical access to care.

Kathleen Potempa (@kathleenpotempa) is the dean of the University of Michigan School of Nursing.

George Halvorson: Relieve Doctors of Their Student-Loan Debts

We definitely need more primary-care doctors in the U.S. One of the major reasons for the current shortage of primary school doctors is the level of medical-school debt that doctors incur on their way to getting their licenses. The smartest thing we could do to get more doctors into primary care might be to forgive medical-school debt for any and all doctors who practice primary care for five to 10 years. That program would actually pay for itself in three years.

How could it pay for itself?

It would pay for itself because the average primary-care doctor now makes about $150,000 a year and incurs roughly $200,000 in debt. The specialty doctors incur slightly more in debt, but they make over $250,000 a year in income. That is $100,000 a year in additional pure salary cost for each doctor.

So if we keep more doctors at the primary-care reimbursement level instead of having them bill for their care at specialty fee levels, we would actually save $100,000 per doctor, per year. Forever.

So forgiving $200,000 in debt one time for each doctor actually saves millions of dollars in fees per doctor, and that-debt forgiveness program can give us the primary-care doctors we need.

Let’s make primary care and medical education debt-free. We will get the primary care we need, and we will save millions of dollars in additional medical fees in the process.

George Halvorson is chairman and chief executive officer of Kaiser Permanente, the nation’s largest nonprofit health plan and hospital system.

Murali Doraiswamy: Don’t Focus on Supply. Focus on Demand.

Reduce demand. I will focus just on one field—psychiatry. Currently, some 40 million Americans are estimated to have a mental illness. These numbers are likely to increase as the field switches to diagnosing people using the new DSM-5 (the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders), which has looser criteria for some common disorders. And some of the newer conditions under discussion in DSM-5, such as Caffeine Use Disorder and Internet Gaming Disorder, could in theory affect tens of thousands more (including I suspect many reading this blog!). Psychiatric drugs have become the nation’s top-selling drugs to the point where measurable levels of drugs such as Prozac and Zoloft can be detected in the public water supply. Minting more psychiatrists is one solution—but this may also simply create a supply-side cycle leading to more diagnoses and more pills.

Unless we want a nation dependent on psychiatric pills, we should broaden our narrow definition of a normal healthy mind and prioritize ways to enhance our mental resilience. Diversity of the mind is just as important as diversity in nature. As a society we should nudge people away from seeking a pill for every minor ill. Resilience results from stronger family ties and relationships and healthier lifestyles (e.g. meditation, more group activities in nature). There is a vast literature on positive psychology—attributes and practices that allow people to flourish and be happy—that can be taught to new psychiatric residents and implemented on a societal scale. We should prioritize neuroscience research into serious mental diseases such as bipolar disorder or schizophrenia, so we can better classify these disorders and find better treatments. Toward this goal, the NIMH (National Institute of Mental Health) has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science and other levels of information to lay the foundation for a new classification system.

The DSM-5 serves a purpose for ensuring we as a society get the care we seek and to provide a common language for providing care. And certainly psychiatric drugs have helped millions of people, so I am not suggesting otherwise. But to paraphrase the noted physician and jurist Oliver Wendell Holmes, “If most of our diagnoses and medicines were to be thrown away into the sea, it might be bad for the fish and good for humanity.” Training more psychiatrists who are mindful of these issues is the best solution.

Dr. P. Murali Doraiswamy is professor of psychiatry and medicine at Duke University Medical Center, where he also serves as a member of the Duke Institute of Brain Sciences and as a senior fellow at the Duke Center for the Study of Aging and Human Development.

Harlan Krumholz: Our Assumptions Could Be Impairing Us

We need to think differently about health-care delivery and extend the reach of doctors rather than organize their days around documentation, clerical activities and tasks that can be handled by other health-care professionals. We have yet to determine an optimal number of physicians and how best their time ought to be allocated. We know that the amount of time that doctors spend with patients is shrinking. Physician burnout is highly prevalent. Many activities done by doctors don’t require their level of training and education. Appointments in many areas of the country can be hard to obtain.

When I was a student I saw such shortages solved by a novel program in North Carolina that placed nurse practitioners in community-build health centers and provided them support to deliver basic primary care. I spent four months interviewing patients and found that they loved the system and the access to care it provided. What I learned was that our assumptions about how care should be delivered might be impairing our ability to provide the best care and to do so with greater efficiency.

We can alleviate any shortages and improve the work conditions at the same time by better organization of the way we deliver care. We need to re-envision the work of doctors and how best to leverage their time. We should begin with a commitment to developing systems that match physicians with tasks that uniquely require their contributions. They should be supported in the clerical and documentation tasks. To the extent possible, other health-care professionals should be working with physicians as a team, taking on tasks that match their professional competencies. We should be employing telemedicine to spread the access to health-care professionals. The system ought to be allocating the professional resources in ways that will increase positive interactions with patients, facilitate communication and coordination, achieve the best outcomes, and promote job satisfaction. We have work to do to achieve that.

Dr. Harlan Krumholz (@HMKYale) is a cardiologist and the Harold H. Hines Jr. professor of medicine and epidemiology and public health at Yale University School of Medicine.

Fred Hassan: Make It Easier to Become a Doctor

Make it easier to become a primary-care doctor in the U.S.

—Benchmark premedical and medical-school costs with other advanced countries and find ways to drop the present total price tag of about half a million dollars to become a doctor in the U.S. This cost in the U.S. can be double that of many other countries.

—Open up more medical-school and residency slots so that the “mission impossible” image of getting into a U.S. med school is mitigated.

—If all else fails, accelerate the trend for nurse practitioners and physician assistants to do more prevention counseling, diagnosis and treatment of easier-to-manage conditions.

Fred Hassan is the chairman of Bausch & Lomb

Bob Wachter: Location Is the Problem, Not Quantity

There really isn’t a doctor shortage in the U.S.; there is a doctor maldistribution, both geographically and by specialty. There are plenty of psychiatrists and cardiologists in New York and San Francisco, but nowhere near enough primary-care doctors virtually everywhere. America is one of the few countries that doesn’t intervene to ensure the right mixture and distribution of its physicians.

To fix the problem, we need to do a few things. First, we have to address physician payment disparities. The economic incentives are completely skewed. For example, it’s just nuts that the average dermatologist or radiologist earns twice as much as the average primary-care doctor. In the United Kingdom, general practitioners make about the same amount as specialists.

Secondly, we need some real workforce planning. If we need more primary-care doctors and fewer anesthesiologists, the federal government should adjust the subsidies they give to the academic medical centers, which determine the number of training slots.

Third, we need to continue to encourage the adoption of new technologies and the thoughtful use of non-physician providers. Our health-care system should be one in which physicians are only doing the work that they are uniquely qualified to do, and other clinicians (or patients and families themselves, supported by appropriate people and technology tools) are doing the work that they can do. If we get this right, it will lead to care that is both better and cheaper.

With the evidence that about 30% of U.S. health-care expenditures add little value for patients, and that physician-specialists create their own demand (when another orthopedic surgeon moves to town, it doesn’t lower prices through competition, it raises utilization and overall costs, a phenomenon known as supply-driven demand), training more physicians isn’t the best way to address our problems. It’s like putting more captains aboard a sinking ship. Let’s plug the holes first.

Robert M. Wachter (@Bob_Wachter) is professor and associate chairman of the Department of Medicine at the University of California, San Francisco, and chair of the American Board of Internal Medicine. He is the author of a textbook on patient safety, “Understanding Patient Safety,” and blogs at www.wachtersworld.org.

J.D. Kleinke: Increase the Number of ‘Non-Doctor’ Doctors

We already do have a shortage of primary-care physicians in the U.S., and the “crowding in” of tens of millions of new Americans with access to coverage under the Affordable Care Act in the next few years will exacerbate the situation. (For the record, more people with more access to primary and preventive care is a good problem to have.) But there will be an aggravated supply problem associated with the release of this pent-up demand, and there are two ways to address it.

First, we can and should significantly expand all efforts and incentive programs (e.g., like the National Health Service Corps http://nhsc.hrsa.gov/) that will increase the number of “non-doctor” doctors, also known as “physician-extenders.” We can train and mobilize these types of providers—physician-assistants, certified nurse practitioners and certified nurse midwives—much faster and for far less cost than we can traditional physicians. And there is an added social and economic benefit: These are good-paying, high-skills based jobs, and would be excellent first (or second) career paths for many highly competent students (or displaced workers) struggling to find good employment in a sluggish job market.

Second, we can and should expand the scope of practice for other “non-doctors” to allow for many other types of caregivers to provide services currently off-limits to them, thanks to ferocious turf defenses by physician lobbies at the state level. The most obvious expansions involve allowing drug prescribing by clinical psychologists and continuing medical management by pharmacists, but they also include many other types of care that could be safely and effectively provided by chiropractors, naturopaths and others with state-regulated training, certification and licensing programs. This can be led by guidance and standard-setting at the federal level, but it will require hard stare-downs on traditional physician lobbies at the state level, and an expansion of payment eligibility by health-insurance administrators.

J.D. Kleinke (@jdkonhealth) is a medical economist, author, health-care-business strategist and entrepreneur. In 2012, he was a resident fellow of the American Enterprise Institute. Before joining AEI, Mr. Kleinke was co-founder and CEO of Mount Tabor, a health-care information-technology development company.

Gurpreet Dhaliwal: Lack of Access to Care Is the Greater Problem

The predicated doctor shortage will exacerbate the larger issue: The limited access to care that already plagues our health system.

The government should increase funding for residency training to remedy the current shortfall, which prevents all U.S. medical-school graduates from completing their training and become practicing physicians. We should also increase residency opportunities for international medical-school graduates, who disproportionately provide care in rural and underserved areas.

Training programs and training sites that successfully develop generalist physicians (where the greatest need lies), as well as nurse practitioners and physician assistants, deserve the greatest support. Clinics, emergency rooms, and hospitals can serve many more patients when physicians, NPs and PAs are working side-by-side.

Patients should be able to access any of those providers through electronic communication. Many more patients can be served via phone, email, text and videoconferencing than the current mandatory face-to-face interaction, which frequently wastes enormous patient and health-care system resources.

We need more doctors, but also more NPs, PAs, and IT experts, just to reach the modest goal of making basic care available to everyone.

Dr. Gurpreet Dhaliwal is an associate professor of clinical medicine at the University of California San Francisco. He directs the internal-medicine clerkships at the San Francisco VA Medical Center, where he sees patients and teaches medical students and residents in the emergency department, inpatient wards and outpatient clinic.

Leah Binder: An M.D. Isn’t Always Necessary for Care

Before we talk about shortages of doctors, let’s talk about our nation’s capacity to provide services Americans need—and build our future workforce on that platform. That answer won’t come from physicians alone.

Indeed, we need to recognize that not everything physicians do now requires a medical degree, and then we need to distribute our workforce accordingly. For instance, we should follow the recommendations of the IOM (Institute of Medicine) and other leading expert consensus bodies and remove artificial barriers to practice for certain advanced practice professionals. Removing barriers for these nurse practitioners, physician assistants, nurse specialists, nurse anesthetists, midwives and other professionals will allow them to provide the services that they are well educated and fully competent to provide.

Currently, different states impose a variety of regulations to restrict non-physicians from offering certain services, because physician lobbies have fought for those restrictions, at least in part to protect their turf. Decades of studies show that these restrictions don’t help patients or improve quality. Given the looming shortages of physicians and other caregivers, it’s time to vastly expand our nation’s capacity by harnessing the wealth of talent in a variety of health-care professions.

Leah Binder (@LeahBinder) is president and chief executive of Leapfrog Group, a national organization based in Washington, D.C., representing employer purchasers of health care and calling for improvements in the safety and quality of the nation’s hospitals.

Atul Grover: Increase Federal Funding for Residency Training

A growing, aging population demands that we train more doctors. Medical schools are doing their part by increasing enrollment. But that won’t result in one additional doctor in practice unless Congress and the administration lift the freeze on federal support for the residency training that has been in place since 1996. You can read more about my argument in the debate in the Journal Report on Big Issues in Health Care.

Dr. Atul Grover is chief public-policy officer of the Association of American Medical Colleges.

John Sotos: Let Doctors Be Doctors

In 1905, Dr. William Osler—the great co-founder of Johns Hopkins Hospital, who was cursed with a terrific sense of humor—jokingly proposed that all men over age 60 should be euthanized. Unfortunately for Osler, the newspapers took him seriously. A gigantic controversy erupted, and Osler spent the rest of his time in America trying to explain himself before fleeing to Oxford.

Being a man not far from the aforementioned age, let me be clear: I don’t support any form of mandatory euthanasia as a method of reducing physician workload. There are much better ways.

I think that physicians should do only “physicianing.” The trends in medicine, however, are exactly the opposite: Physicians are wasting increasing amounts of time doing “un-physiciany” things. They are being de-professionalized.

The painting, titled “The Doctor,” appeared in 1891. The sick child commands every ounce of the doctor’s attention and concentration. The drawing, untitled, appeared in 2012. The sick child, who is also the artist, sits on an examination table, amid family. The physician is at the left margin, his head down, the hospital information system commanding every ounce of his attention and concentration.

If you talk to physicians today, every single one of them will begrudge the time they spend feeding the gaping, information-eating maw of insurers and medicine-practiced-by-teams. Some may admit there are benefits, but every single one will talk about the costs, which are all too obvious.

If Dr. Leonard “Bones” McCoy were among us, he would rightly and indignantly remind Captain Kirk that, “Dammit, he’s a doctor, not a stenographer.”

Dr. John Sotos, a cardiologist and flight surgeon, was a medical technical adviser to the television series “House, M.D.” and is the author of several books, including “The Physical Lincoln.” His home page is www.sotos.com.

Carol Cassella: If We Want More Doctors, We Have to Pay for More Training

Despite much doom and gloom spouted by practicing physicians about the future of U.S. doctors’ autonomy and incomes, medicine is still a popular career choice. Medical school applications reached an all-time high as of 2011, and new medical schools are being opened to accommodate them. The problem is that after four years studying basic sciences and elementary patient care, medical-school graduates hit a bottleneck when they apply for a residency. That critical and expensive leg of training, without which one cannot be board certified, hasn’t seen a federal funding increase since 1997. Increased funding was proposed in the Affordable Care Act, but it wasn’t approved. Meanwhile, every year more physicians age out of full-time practice, and more aging patients need physicians. So the shortage grows. In the long term, if we want more doctors we have to pay more for their training.

But what about the short term? Beyond sheer numbers, the distribution of doctors is also a problem, both across specialties and across geographical and income parameters. That, too, might boil down to economics. As of 2012, 86% of medical-school graduates started practice with debts averaging more than $166,000, and the income gap between primary care and procedure-heavy specialties is millions of dollars over a lifetime. These realities have enormous influence over young doctors’ career decisions. Is it time to consider narrowing the pay gap? Should we reduce medical tuition in exchange for mandatory one- or two-year service programs? Voluntary service-for-tuition programs haven’t been very popular but they are gaining ground and support. Given how much the government and taxpayers invest in training physicians, maybe some service shouldn’t be voluntary.

Dr. Carol Cassella (@CarolCassella) is a practicing physician and author of the novels “Oxygen” and “Healer.”

Peter Pronovost: Make Being a Doctor More Rewarding

Policy makers must make sure there are enough residency positions for the bright, talented students graduating from medical school. As my colleague Atul Grover from the Association of American Medical Colleges points out, Congress and the administration put a cap on support for residency training in 1996 and, unless that cap is lifted, all the other efforts in the policy arena “still won’t result in one more doctor in practice.”

In addition to increasing the number of residency training positions, other incentives are needed to create a rewarding work environment that provides purpose, supports autonomy, develops mastery and presents financial rewards.

Bureaucratic hassles and changing reimbursement rates for services influence what specialties physicians choose. For example, fewer medical students are pursuing careers in primary care, which pays less than specialty care but requires the same investment in terms of student loans—nearly $200,000 on average per student. Physicians also report high rates of burnout: One in three plans to leave the profession in the next three years.

Lower pay and high—even dangerous—workload has reduced the number of critical-care physicians. When critical-care physicians staff intensive-care units, mortality and costs are reduced by 30%. Yet only three out of 10 U.S. hospitals have these lifesaving physicians, in part because there aren’t enough of them.

Policy makers can create incentives to encourage physicians to go into needed specialties by increasing payments and reducing the burden of student loans. They can also help make careers in medicine more rewarding by giving physicians more autonomy. We can maintain autonomy and ensure safe care is delivered by creating mechanisms that hold physicians accountable for patient outcomes and encourage them to innovate on how to improve those outcomes.

Peter Pronovost is a practicing anesthesiologist, critical-care physician, professor, Johns Hopkins Medicine senior vice president and director of the Armstrong Institute for Patient Safety and Quality.

Susan DeVore: Leverage Under-Used Care Providers

With the impending influx of Medicare and Medicaid patients, coupled with our aging physician workforce, our country’s physician-shortage problem is poised to only worsen.

Let’s be clear—there’s no way to replace the care a physician provides when it is needed. But one way to alleviate physician shortages is to leverage underutilized agents in the clinical and community setting, such as nurses and other care providers.

For example, Mercy Health in Cincinnati has introduced a coordinated-care program that works in both inpatient and outpatient settings. Care-management team nurses communicate with patients at home and through regular phone calls, providing coaching as needed. The nurses also teach health-education classes and refer patients with mental health and life management issues to behavioral-health counselors for further assistance.

They’ve also found that the best means of treating a patient may have nothing to do with clinical care. In some cases, improving their mental outlook could be the motivation they need to avoid admission. In one example, Mercy Health nurses found that one of their patients with a chronic condition had no furniture at home, except a bed. Mercy Health supplied her with a chair, promoting mobility while allowing her to look out the window and gain a different perspective.

In some cases, we might safely question whether a clinician is required, or is as effective, as someone else.

Heartland Health President and CEO Mark Laney, M.D., recently told a story about an older man who visited one of their new, innovative life-center clinics. He was complaining that he wasn’t feeling well, and wasn’t sure why. Staff at the St. Joseph, Mo.-based health system came to find out that his wife of 35 years recently died—turns out, she always did the cooking, which ultimately had a lot to do with why he wasn’t feeling well.

Heartland didn’t treat his temporary problem. They treated the root cause, which was surprisingly not medical in nature: his diet. A non–clinical caregiver called a “life coach” took the man to the grocery store, and taught him how to choose and prepare healthy meals. This is just one example of how Heartland’s model, called Mosaic Life Care, has proved successful for the people they serve, while alleviating the need for physician—and even clinical—care.

Technology can also play a significant role in lessening the physician-shortage impact. For example, the Charlotte, N.C.-based Carolinas HealthCare System is implementing a virtual critical-care program allowing clinicians to remotely monitor patients in intensive-care units at all times. If a problem develops, the intensivist on call can be quickly and easily notified, and intervene. It’s an added level of care, like having a critical-care specialist at each bedside 24/7.

I feel strongly that our country has the best physicians in the world, and there’s nothing that can be done to replace them. But our physician shortage needs to be addressed, and soon. One way to lessen this problem is to ensure people receive the right care, in the right place, at the right time.

Susan DeVore is president and chief executive officer of the Premier Inc. health-care alliance.

David Blumenthal: Allow Nurse Practitioners to Provide More Care

As I discussed in the New England Journal of Medicine last month, one option for addressing the threatened shortage of primary-care doctors in this country is to rely on nurse practitioners to provide a wider range of services. Now numbering approximately 180,000, nurse practitioners have become an important part of the U.S. health-care workforce. The literature shows that nurse practitioners provide many types of routine primary care that is comparable in quality to that provided by primary-care physicians, as measured by health outcomes, use of resources and cost. In some respects, such as communication with patients seeking urgent care, they perform better than physicians.

However, this is a highly complex issue and several important considerations merit further thought and study. First, nurse practitioners and primary-care clinicians receive different training and have different skill sets. Physicians may be more skilled diagnosticians, especially for rare and complex problems. Also, it isn’t yet clear whether nurses can manage patients with multiple interacting chronic conditions with the same skill as physicians. Patients also vary significantly and strongly in their preferences regarding who provides their primary care. And new team-based models of primary-care practice create additional opportunities and uncertainties, perhaps alleviating the predicted shortage of providers by increasing efficiency.

Ultimately, a flexible approach to crafting primary-care-workforce policy is needed, one that is responsive to the changing roles of health-care professionals and to changes in the organization and financing of health care. Policy makers should rely upon objective data on the competencies of professionals—rather than rigid state laws—to regulate providers’ roles. And patients need to be given a voice in the debate.

David Blumenthal (@DavidBlumenthal) is president and chief executive officer of the Commonwealth Fund, a national health-care philanthropy based in New York City.

Drew Harris: Market Forces Will Help, to a Degree

Fixing the doctor shortage will require new policy interventions, but market forces will also play a major role in ensuring everyone with the means will get the care they need.

Research by Stephen Petterson et al projects a shortfall of 52,000 primary-care providers above the current baseline of 210,000 doctors by 2025. Interestingly, demand is driven mostly by a growing (32,852 more doctors needed) and aging (9,894 needed) population. Only 8,097 more providers are needed to cover those newly insured under the Affordable Care Act. This isn’t too surprising considering that the uninsured tend to be younger and healthier, while the older and sick people are more likely to have coverage.

Several policy initiatives could address the shortfall:

• Expand the scope of practice of non-MD providers. By allowing advanced practice nurses, nurse practitioners and physician assistants to practice all that they have been trained to do, which is often more than their states allow, we could free up highly trained physicians to provide more complex evaluation and treatment.

• Increase the number of care delivery sites. In many states, specially trained pharmacists can give all recommended vaccinations. Patients must like this option because pharmacies have outpaced workplaces as the preferred place to get a flu shot.

• Deliver more care in the home. Much of primary care is making sure chronic conditions don’t get worse. New technology provides for continuing monitoring of mental status, blood sugar, blood pressure and other signs of a deteriorating medical condition, resulting in fewer unnecessary checkups and preventable hospitalizations.

• Tie medical school loans to practice in underserved communities. We need to recruit medical students from underserved areas and provide them with loans or grants to ensure they return to practice where they are needed most—not wealthier communities with a physician oversupply.

Finally, the market will respond to millions of newly insured people seeking care. If it isn’t the physicians leading teams of health professionals employing innovative population health delivery models then it will be large corporations such as Wal-Mart Stores Inc. WMT +0.42% and Walgreen Co. WAG +2.47% setting up highly efficient fully integrated care centers staffed with midlevel health providers.

Drew Harris (@drewaharris) is director of health policy at the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, where he focuses on the complex interplay between public health, medical care and public policy.

Pamela Barnes: Think About Teams, Not Just Doctors

It isn’t about finding more doctors; we need to think more strategically about how we deliver health-care services. A team-based approach to health care shifts the concentration from a few doctors providing specialized or even general medical services to an entire team that is able to leverage their skills, knowledge and expertise. In many of the countries where we work, nurses, nurse practitioners and midwives, for example, allow us to reach more women and families, providing the same quality of care as doctors. We need to examine our communities, determine their needs, and develop the types of health-care teams that work best for them.

Pamela Barnes (@PamWBarnes) is the president and CEO of EngenderHealth and was formerly president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation.

Charles Denham: Stop Stifling Medical Assistants

Unfortunately, the physician-dominated guild system that has been U.S. health care has stifled medical assistants, nurses, nurse practitioners, pharmacists and many allied personnel from operating at the top of their intellect, certifications and training. Physician assistants and nurse practitioners many times have more experience in certain processes than the average physicians that they serve, yet they aren’t able to work independently because of the reimbursement structure and ancient regulations that were put in place many decades ago. As will soon be published by the Cleveland Clinic’s Dr. David Longworth, even medical-office assistants can have tremendous impact on quality and the operational performance of a clinic when given the chance to operate at the top of their game.

The great performance-improvement collaborative programs established by the Institute for Healthcare Improvement (IHI), led by Dr. Don Berwick, our recent Medicare leader, and Maureen Bisognono, gave us the gift of rapid cycle innovation that has broken barriers of performance previously unheard of; and their motto was “All Teach—All Learn.” By adding the methods of team-based work process and the concept of servant leadership to caregiving, which is what creates the wonderful healing moments caregivers cherish, a motto of All Teach, All Learn, and All Lead becomes real.

The only way we can address the shortage of doctors is to unleash the creativity and power of millions of caregivers, allied health personnel and assistants who would step up in an instant to take on more responsibility. To quote the global business leader and CEO of Barry Wehmiller Cos. and visionary leader in the coming documentary “Healing Moments—Loved Ones Caring for Loved Ones,” “We have rented their hands for years and could have had their heads and hearts for free…all we had to do was ask.” They are ready…are we?

Charles Denham (@Charles_Denham) is the founder of the not-for-profit Texas Medical Institute of Technology, a medical-research organization, and the for-profit HCC Corp., an innovation accelerator.

Helen Darling: Encourage a Team Effort

The first step should be to make certain that health care is being delivered in the most efficient and effective ways with each team member practicing to the “top of his or her license.” Physicians should work in teams with other health professionals who take on tasks that don’t require a physician. Advanced practice nurses and RNs can do more than they usually do and, in turn, jobs that they do may be just as well done by a paraprofessional, freeing them for those activities for which they are licensed and already highly qualified. There are dozens of examples, and doctors are likely to enjoy practicing much more if they are freed from tasks that don’t require their advanced training.

There is substantial research that nurses, nutritionists, pharmacists, and so forth, can deliver care, education, and information much better with greater impact than physicians, yet the way we all pay for care often means that if the doctor doesn’t provide the service, it isn’t reimbursable. Patient-centered, team-based care could significantly decrease the demand for additional doctors.

With the right system re-engineering and electronic health records, time spent now by doctors could be replaced or eliminated by smart technology. Once all possible steps have been taken to optimize roles and responsibilities of highly skilled and expensively educated doctors, then an independent assessment by an objective, credible group should analyze data and make recommendations for which specialists (e.g. general surgeons) are truly needed, in addition to the primary-care doctors and advanced practice nurses needed now. Medical-school classes (and relevant residencies) might be enlarged slightly to accommodate any gaps, but the nation shouldn’t build more medical schools. They are remarkably expensive and once built will need to be supported, predominantly with public funds. This would add way more to the costs of health care at a time when we need to be finding ways to reduce costs, not add to them.

Helen Darling is president and chief executive officer of the National Business Group on Health, a Washington, D.C.-based nonprofit member organization composed of more than 360 of the nation’s largest employers, including 66 of the Fortune 100.

Related Articles

The six, who are all vascular surgeons, all raised concerns about the quality of the data or methods used to adjust the statistics to take into account risk factors such as the patient’s health and age.

The performance league tables have been hailed as a world first and are aimed at making surgeons more accountable.

In total data on 3,500 surgeons from 10 specialities are to be published by the autumn, with the majority being made public next week.

Richard Bird, a consultant vascular surgeon at Barnet General Hospital, was among those who did not give permission for his mortality rates to be released.

He is currently the Royal College of Surgeon’s Programme Director for core surgical trainees in North East London.

He cited concerns about the quality of the data and its completeness as the reason for not giving consent.

Patrick Kent, a consultant vascular and general surgeon at St James University Hospital in Leeds, also refused for the same reasons, adding that he did not agree with the publication of consultant level outcomes and had concerns about the risk adjustment methodology.

Robert Lonsdale, a consultant vascular surgeon at Northern General Hospital in Sheffield, also gave the same reasons.

Manmohan Madan, a consultant vascular surgeon at North Manchester General Hospital, said he did not agree with the data quality.

He declined to comment further.

Professor Peter McCollum, chair in vascular surgery at Hull York Medical School and a consultant vascular surgeon at Hull Royal Infirmary, said he did not agree with the publication of the data.

Leszek Wolowczyk, a vascular and general surgeon at Tameside General Hospital in Ashton under Lyne refused to say why he withheld his data.

Some of the surgeons, however, are believed to be concerned that operations they perform alongside other surgeons were not to be included in the data and so would not give an accurate picture of their outcomes.

Professor Ben Bridgewater, outcomes publication director of the Healthcare Quality Improvement Partnership who led the collection of the data, said that very few in total had refused to release data.

Just 20 out of the 3,500 surgeons had chosen to withhold their data in total.

Professor Bridgewater said he expected that figure to decrease by the time the final wave of releases are made in the autumn.

He said: “I encouraged everyone to give consent, but some people didn’t want to. We asked them what their reasons were.

“They were primarily about concerns about the quality of the data and the risk adjustment.

“None of those who withheld consent have mortality rates that are higher than expected, so this idea that they are trying to hide bad results is not true.

“Most people are performing to an acceptable standard so I hope patients will be reassured by that.

“When there is variation that is not acceptable, because the system is open and transparent, people be dealing with it in a way that hasn’t been in the past.”

In the first set of figures to be released, from 458 vascular surgeons covering 21,000 operations over five years, some doctors had mortality rates that were up to 14 times the national average.

One surgeon’s figures that nearly one in three people he treated for a particular type of operation ended up dying.

On Friday morning cardiothoracic surgeons also released their data, which showed that for one surgeon, 15 per cent of the patients he operated on had died.

The majority, however, had mortality rates around two or three per cent.

Professor Sir Bruce Keogh, medical director for NHS England, hailed the release of mortality figures as a “major breakthrough” for transparency in the NHS.

“This is a major cultural change in the way the NHS works and we expect this to take time to bed in.

“A small number of surgeons have so far not consented to their data being published but, as is our experience with the publication of cardiac data, we expect this to change over time with more consultants agreeing to their data being published.

“Now I expect hospitals and surgeons to use this information to judge the outcomes their patients are getting.”

Here at Poor Richard’s News, we’ve done our best to document how Obamacare is killing the greatest healthcare system in the world. Well here’s yet another example: there aren’t enough doctors to cover its mandates.

As the state moves to expand healthcare coverage to millions of Californians under President Obama’s healthcare law, it faces a major obstacle: There aren’t enough doctors to treat a crush of newly insured patients.

Some lawmakers want to fill the gap by redefining who can provide healthcare.

They are working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices. Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high-blood pressure.

“We’re going to be mandating that every single person in this state have insurance,” said state Sen. Ed Hernandez (D-West Covina), chairman of the Senate Health Committee and leader of the effort to expand professional boundaries. “What good is it if they are going to have a health insurance card but no access to doctors?”

Hernandez’s proposed changes, which would dramatically shake up the medical establishment in California, have set off a turf war with physicians that could contribute to the success or failure of the federal Affordable Care Act in California.

Doctors say giving non-physicians more authority and autonomy could jeopardize patient safety. It could also drive up costs, because those workers, who have less medical education and training, tend to order more tests and prescribe more antibiotics, they said.

Such “scope-of-practice” fights are flaring across the country as states brace for an influx of patients into already strained healthcare systems. About 350 laws altering what health professionals may do have been enacted nationwide in the last two years, according to the National Conference of State Legislatures. Since Jan. 1, more than 50 additional proposals have been launched in 24 states.

Obamacare forces “free citizens” to get health insurance with no regard to one of the obvious consequences: Doctor shortages. And when elected officials are forced to finally face this reality, their solution is not to repeal the ridiculous mandate, but to redefine what it means to be a doctor. It’s surreal.

This proves two things (other than that Obamacare is awful in general):

1) When people have insurance, many times they go to the doctor when they don’t need to. It’s one of the reasons insurance is so expensive to begin with. If, say, I had hotel insurance, you can bet that I wouldn’t be staying in the Red Roof Inn. I’d be staying at the Ritz Carlton. The same thing is true for health insurance. A young, healthy person may choose not to have insurance, which will dissuade them from going to the doctor every time they sneeze. But if they have health insurance, why not go?

2) By redefining what it means to be a doctor, government officials are recognizing one of the major flaws of the legislation. I doubt they would admit this, but what other conclusion can one draw?

Why didn’t Obamacare train and Qualify More Doctors?

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There are just not enough doctors to take care of all Americans as envisioned by President Obama…..

By Annie Lowrey and Robert Pear
The New York Times

July 28, 2012

RIVERSIDE, Calif. — In the Inland Empire, an economically depressed region in Southern California, President Obama’s health care law is expected to extend insurance coverage to more than 300,000 people by 2014. But coverage will not necessarily translate into care: Local health experts doubt there will be enough doctors to meet the area’s needs. There are not enough now.

Other places around the country, including the Mississippi Delta, Detroit and suburban Phoenix, face similar problems. The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.

Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor.

“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.”

Experts describe a doctor shortage as an “invisible problem.” Patients still get care, but the process is often slow and difficult. In Riverside, it has left residents driving long distances to doctors, languishing on waiting lists, overusing emergency rooms and even forgoing care.

“It results in delayed care and higher levels of acuity,” said Dustin Corcoran, the chief executive of the California Medical Association, which represents 35,000 physicians. People “access the health care system through the emergency department, rather than establishing a relationship with a primary care physician who might keep them from getting sicker.”

In the Inland Empire, encompassing the counties of Riverside and San Bernardino, the shortage of doctors is already severe. The population of Riverside County swelled 42 percent in the 2000s, gaining more than 644,000 people. It has continued to grow despite the collapse of one of the country’s biggest property bubbles and a jobless rate of 11.8 percent in the Riverside-San Bernardino-Ontario metro area.

But the growth in the number of physicians has lagged, in no small part because the area has trouble attracting doctors, who might make more money and prefer living in nearby Orange County or Los Angeles.

A government council has recommended that a given region have 60 to 80 primary care doctors per 100,000 residents, and 85 to 105 specialists. The Inland Empire has about 40 primary care doctors and 70 specialists per 100,000 residents — the worst shortage in California, in both cases.

Moreover, across the country, fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008, making it hard for the poor to find care even when they are eligible for Medicaid. The expansion of Medicaid accounts for more than one-third of the overall growth in coverage in President Obama’s health care law.

Providers say they are bracing for the surge of the newly insured into an already strained system.

Temetry Lindsey, the chief executive of Inland Behavioral & Health Services, which provides medical care to about 12,000 area residents, many of them low income, said she was speeding patient-processing systems, packing doctors’ schedules tighter and seeking to hire more physicians.

“We know we are going to be overrun at some point,” Ms. Lindsey said, estimating that the clinics would see new demand from 10,000 to 25,000 residents by 2014. She added that hiring new doctors had proved a struggle, in part because of the “stigma” of working in this part of California.

Across the country, a factor increasing demand, along with expansion of coverage in the law and simple population growth, is the aging of the baby boom generation. Medicare officials predict that enrollment will surge to 73.2 million in 2025, up 44 percent from 50.7 million this year.

“Older Americans require significantly more health care,” said Dr. Darrell G. Kirch, the president of the Association of American Medical Colleges. “Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.”

The pool of doctors has not kept pace, and will not, health experts said. Medical school enrollment is increasing, but not as fast as the population. The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement.

Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.

The Obama administration has sought to ease the shortage. The health care law increases Medicaid’s primary care payment rates in 2013 and 2014. It also includes money to train new primary care doctors, reward them for working in underserved communities and strengthen community health centers.

But the provisions within the law are expected to increase the number of primary care doctors by perhaps 3,000 in the coming decade. Communities around the country need about 45,000.

Many health experts in California said that while they welcomed the expansion of coverage, they expected that the state simply would not be ready for the new demand. “It’s going to be necessary to use the resources that we have smarter” in light of the doctor shortages, said Dr. Mark D. Smith, who heads the California HealthCare Foundation, a nonprofit group.

Dr. Smith said building more walk-in clinics, allowing nurses to provide more care and encouraging doctors to work in teams would all be part of the answer. Mr. Corcoran of the California Medical Association also said the state would need to stop cutting Medicaid payment rates; instead, it needed to increase them to make seeing those patients economically feasible for doctors.

More doctors might be part of the answer as well. The U.C. Riverside medical school is hoping to enroll its first students in August 2013, and is planning a number of policies to encourage its graduates to stay in the area and practice primary care.

But Dr. Olds said changing how doctors provided care would be more important than minting new doctors. “I’m only adding 22 new students to this equation,” he said. “That’s not enough to put a dent in a 5,000-doctor shortage.”

Annie Lowrey reported from Riverside, and Robert Pear from Washington.

The battle-lines have formed and skirmishes are breaking out as doctors across the nation, particularly in Florida, struggle to regain relevance in today’s healthcare environment. Prior to passage of President Obama’s massive healthcare system overhaul, polls across America revealed that a large majority of non-medical voters and an even larger majority of doctors disapproved of the extent of the proposed legislation. Disregarding the majority’s wants, Congress passed and the President signed into law the Patient Protection and Affordable Care Act. The bill was supported, but not totally endorsed, by the American Medical Association (AMA). This support has created tension between the Florida Medical Association (FMA) and the AMA.

By Larry N. Smith, M.D.
The Hill
September 29, 2010

The AMA found itself in a difficult position at the start of the reform debate. It had fought and won many political battles to prevent partial or complete national healthcare models from being instituted. From President Franklin Roosevelt on, the AMA had been able to negotiate effectively for its membership while still maintaining its core mission of improving healthcare for Americans. During this most recent debate, the AMA found itself in a disadvantaged position. Having seen a sister medical organization completely excluded from the negotiations for taking a hard stand against this reform package, the AMA leadership realized that it had to be “at the table.” The leadership worked towards meaningful input into the legislation despite the competitive, complicated, and multi-interested nature of the negotiations.

The AMA’s participation allowed it to negotiate against an experienced group of reform advocates including Rahm Emanuel and Nancy-Ann Min DeParle — both Clinton-era healthcare veterans. In addition, both houses of Congress were in the grips of reform-minded Democrats with little sympathy for doctors. As news of each major reform was released, doctors and state medical societies vociferously resisted the changes. The laws would forever alter the practice and even content of medicine. It was then that AMA membership levels began dropping, and doctors’ outcries of no confidence began.

Many doctors believe that the AMA was giving up doctors’ rights to independent medical practice for cosmetic gains. Doctors were banned from owning hospitals or other healthcare facilities, which is exactly what they had historically done: the Mayo Clinic, the Cleveland Clinic and the Ochsner Clinic are three prime examples. In addition, doctors were being forced into “Accountable Healthcare Organizations,” meaning they would become paid employees. The SGR formula was not fixed, so doctors still face a substantial 21 to 35 percent fee reduction in the next several months. More cuts will follow in order to meet budget projections, as noted on page fourteen of the Congressional Budget Office report to Speaker Nancy Pelosi. Even though the AMA was successful in preventing the newly established Comparative Effectiveness Committee’s findings from being used to dictate practice decisions, deny treatments, or set payments, the committee still establishes the effectiveness of treatments. It is hard to imagine that this data will not be drawn upon to make policy.

From within this assault on medicine, dissatisfaction with the AMA’s ability to represent Florida physicians grew, and the Florida Medical Association met to discuss the AMA’s actions. The odium towards the AMA was only inflamed when the leadership gave support to Obama’s pick to lead CMS — Dr. Donald Berwick. His beliefs about redistribution, socialist healthcare delivery systems, and healthcare rationing are well documented. During the FMA’s Orlando meeting, Jeff Goldsmith, a PhD from the University of Virginia and a recognized expert on healthcare legislation, validated every fear that organized medicine had about the bill. Medicine in the future will be delivered by large multi-specialty hospitals, with capitated coverage and risk-sharing systems; doctors will be employed by these systems, many in shift work. This change has already started, as noted by a survey taken at a FMA meeting revealing only 30 percent of doctors are still in solo private practice. Private medical and academic practitioners are concerned about their future as independent professionals.

At the meeting, civil and sometimes stinging arguments for and against secession from the AMA were debated. Ultimately in a 52% to 48% vote, the decision to put the AMA on notice and remain a collective body passed. The members of Congress have long recognized the AMA as the single most important voice for medicine, invariably asking the AMA’s position on any issue. The FMA and the 49 other state medical societies know that without a single voice the opposition to the free practice of medicine will be empowered. The AMA tried and succeeded in this round of reform to preserve some sanctity to the doctor-patient relationship by keeping the government from coming completely between it, but future changes could still undo this relationship. Granted there are marked regional variations in doctors’ vision of healthcare reform. Understanding this, the FMA House of Delegates came to the right decision to sanction but not secede from the AMA. Without a single respected and experienced voice at future negotiations, no administration is going to listen to the blather of dozens of separate organizations. The AMA accomplished much in this reform battle but the war is not over, since so many believe only a single-payer national healthcare system is the answer. If for nothing but the sake of America’s constitutional liberties and the freedom to practice as one chooses, this must be prevented and it is the voice of the AMA that will lead that fight. But it has been placed on notice and may find itself alone if it continues to lose the big battles in this war.

Dr. Smith is a historical novelist and has written extensively on medical economics. He is an adjunct faculty member at Santa Fe College, a Fellow in the American College of Surgeons, and delegate to the FMA House of Delegates